Amid concerns that STAR Flight is being underused, Travis County officials have asked Austin-Travis County Emergency Medical Services to review why a ground ambulance was dispatchedinstead of a helicopter to take patients to the hospital in a handful of incidents.

Danny Hobby, who runs emergency services for the county, said the reviews could show that using a ground ambulance was the best way to take patients to the hospital but that EMS officials need to make sure each response was appropriate.

The city of Austin runs EMS, but the county annually funds part of the agency to provide ambulance services outside city limits. The county’s requests come as city and county officials grapple with how to best expand EMS services to county residents.

Ernie Rodriguez, who heads EMS for the city, said he doesn’t know of any situations in which STAR Flight, which provides air ambulance service for the agency, should have been called but was not.

The EMS medical director’s office reviews any issues presented to the agency, officials said. However, the office’s findings will not be released, they said, citing a section of the state’s health and safety code relating to the confidential communications of emergency medical services.

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Though statistics are not tracked on how many times STAR Flight was deployed in the city versus the county, the helicopter is primarily used outside of city limits, STAR Flight program manager Casey Ping said. STAR Flight has flown patients in the county and the city about 600 times since fiscal 2009, according to county data, with the number of flights dropping slightly over the years. In fiscal 2009, STAR Flight took patients about 170 times. In 2010, there were about 160 such trips, about 130 in 2011 and 120 in 2012.

According to emails between county and EMS officials obtained by the American-Statesman, Ping aired concerns to EMS medical director Paul Hinchey and other EMS and county officials in February about “multiple cases” in which he said STAR Flight had responded to a call and was overhead when it was canceled. Meanwhile, he said, additional ambulances were requested or it took an ambulance a long time to get to the hospital.

The county has made written requests to the city to review six incidents or issues regarding what resources were used to respond to a call,Ping said.

One such incident, Hobby said, was a lightning strike in Bee Cave on April 29 that injured three people. Medics took the three patients, two in critical condition, to University Medical Center Brackenridge, about 30 minutes away not accounting for traffic. He wondered why multiple EMS units stationed in the county were dispatched to respond to the call when STAR Flight could have been used.

EMS officials said they could not comment on the specific incidents the county raised questions about, but Rodriguez said the agency constantly reflects on what’s best for patients, including whether they would have benefited from using STAR Flight.

“Before we fly a lot of helicopters over residences and city streets, we have to be very careful about what the benefit is to the patient,” Rodriguez said. “A lot of times panic will dictate that we should use a helicopter, but medical judgment will show that there’s very little benefit in flying a patient.”

Ping, among others, has expressed concerns that STAR Flight should have been used instead of ambulances to take patients to the hospital.

In early February, Ping received an email from a STAR Flight paramedic wondering why it took 45 minutes to get a baby in serious condition to Dell Children’s Medical Center.

Austin-Travis County EMS sent medics to the baby’s home at 5:11 p.m., according to the email, which doesn’t specify a date. When medics arrived, the baby’s condition was a “priority 1 trauma,” the email says. They left the home about 20 minutes after getting there, and 25 minutes later pulled into the hospital, where a trauma team took over.

Considering rush-hour traffic, the STAR Flight paramedic asked the responding EMS medics why they hadn’t requested the helicopter, according to the email. They said it was because the computer-aided dispatch system EMS uses wouldn’t let them since it calculated the transport time — the time it takes medics to arrive at a scene — at less than 20 minutes.

In asking several EMS officials to review the incident, Ping said he was most concerned by “the perceived comments about what authority ATCEMS personnel have or do not have to make transport decisions. This is not the first time we have been told they aren’t allowed to request STAR Flight.”

Jasper Brown, an acting assistant chief for EMS, said that the system recommends STAR Flight respond to calls flagged as having the highest and second-highest priorities if the closest ambulance is more than 20 minutes away from the scene of the call. But once medics arrive at the scene, they can request STAR Flight regardless of the call priority, Brown said, a decision that’s based on the patient’s medical condition, among other factors.

Tony Marquardt, president of the Austin-Travis County EMS Association, said it’s “preposterous” to think the agency would use STAR Flight as a first response unit, saying it’s a terrible financial decision that could send patients into medical bankruptcy.

“It’s a very expensive solution to a problem that’s been created by not giving us our resources,” Marquardt said, referring to an ambulance service expansion that the county has delayed funding.

A STAR Flight trip costs $3,400 plus $85 per loaded mile for Travis County residents and $7,500 plus $85 per loaded mile for people who don’t live in the county, Ping said. Insurance could cover those costs, he said, or patients can set up a payment plan, with some paying $20 per month.

In an April email to county officials, Ping criticizes how existing resources are being used to respond to calls, saying it seems hard to defend spending millions on more ground ambulances when “we can’t use the resources we already have.”